Association of race and health insurance in treatment disparities of colon cancer: A retrospective analysis utilizing a national population database in the United States

Abstract

Background Both health insurance status and race independently impact colon cancer (CC) care delivery and outcomes. The relative importance of these factors in explaining racial and insurance disparities is less clear, however. This study aimed to determine the association and interaction of race and insurance with CC treatment disparities. Study setting Retrospective cohort review of a prospective hospital-based database. Methods and findings In this cross-sectional study, patients diagnosed with stage I to III CC in the United States were identified from the National Cancer Database (NCDB; 2006 to 2016). Multivariable regression with generalized estimating equations (GEEs) were performed to evaluate the association of insurance and race/ethnicity with odds of receipt of surgery (stage I to III) and adjuvant chemotherapy (stage III), with an additional 2-way interaction term to evaluate for effect modification. Confounders included sex, age, median income, rurality, comorbidity, and nodes and margin status for the model for chemotherapy. Of 353,998 patients included, 73.8% (n = 261,349) were non-Hispanic White (NHW) and 11.7% (n = 41,511) were non-Hispanic Black (NHB). NHB patients were less likely to undergo resection [odds ratio (OR) 0.66, 95% confidence interval [CI] 0.61 to 0.72, p Conclusions This study suggests that racial disparities in receipt of treatment for CC persist even among patients with similar health insurance coverage and that different disparities exist for different racial/ethnic groups. Changes in health policy must therefore recognize that provision of insurance alone may not eliminate cancer treatment racial disparities. Scarlett Hao and colleagues utilize a national population database to investigate the association of race and health insurance in treatment disparities of colon cancer in US. Author summary Why was this study done? Patients of Black and Hispanic race and ethnicity have a higher incidence of colon cancer (CC), are diagnosed with more advanced disease, and have poorer survival than White patients. Patients with Medicaid insurance and those without insurance also present with more advanced disease and have poorer outcomes. The role of insurance status in explaining these racial disparities is not well understood. What did the researchers do and find? We identified patients diagnosed with stage I to III CC within the National Cancer Database (NCDB) from 2006 to 2016. We investigated factors associated with receiving surgical removal of the cancer as well as chemotherapy after resection. We found that Black patients were less likely to undergo surgical removal and receive chemotherapy, and Hispanic patients were less likely to undergo surgical removal controlling for insurance type. We also found that patients with Medicaid and those without insurance also were less likely to undergo surgical removal and receive chemotherapy. We also found that even in patients with private and Medicare insurance, those that were Black or Hispanic were less likely to undergo surgical removal and that those that were Black also were less likely to receive chemotherapy after removal. What do these findings mean? Results from this study suggest that even with private and Medicare insurance, certain underrepresented and underprivileged minorities such as Blacks and Hispanics are still less likely to receive standard of care for CC. Simply providing these patients with health insurance alone may not be enough to reduce these disparities. Different minorities, such as Blacks and Hispanics, have different disparities in regard to CC treatment. Additional research needs to be performed to identify factors that are preventing Blacks and Hispanics from receiving the standard of care for CC outside of health insurance.